Preventive Medicine

Previous studies on screen use and childrens mental health during the Coronavirus Disease 2019 (COVID-19) pandemic either focused only on the timeframe during the pandemic, or only on children previously reporting COVID-related severe family economic hardship or worries. Instead, we used a large sample (n=63,211) of the National Survey of Childrens Health (NSCH) years 2018-20 to analyze changes in the trends of recreational screen device use before, versus during the COVID-19 pandemic, and associations with psychological well-being, widely among school-age children (6-17 year-olds) across the US. We assessed recreational screen use, instead of overall use including both instructional and recreational use, and developed psychological well-being issue scores to evaluate the associations among the pandemic, recreational screen use, and psychological well-being states. We found an increase in the prevalence of screen overuse/addiction and psychological well-being issues during the pandemic compared to the years prior, detected an association between the pandemic and psychological well-being issue scores (p <0.01 across all models), and observed increased magnitude of association between recreational screen overuse/addiction and mental health during the pandemic year (p <0.01 across all models). Further studies on elucidating and addressing the specific aspects of the pandemic that contribute to these associations are critical.

BackgroundThe COVID-19 pandemic was associated with an increase in conspiracy theories worldwide. However, the prevalence of COVID-19 conspiracy beliefs among Japanese has remained unclear. This study aimed to estimate the prevalence and correlates of COVID-19 conspiracy beliefs in Japan using a nationwide survey of 28,175 residents aged 16-81 years old. MethodsA nationally representative, cross-sectional self-administered survey was conducted from September to October 2021. To assess the number of COVID-19 conspiracy beliefs, we used three questions from the Oxford Coronavirus Explanations, Attitudes, and Narratives Survey. Independent variables included general vaccine conspiracy beliefs, sociodemographic variables, information sources for COVID-19, trust in authorities, and fear of COVID-19. ResultsAfter applying sampling weights and imputation, the estimated prevalence of holding at least one COVID-19 conspiracy belief was 24.4%. From a linear regression model, several factors were independently associated with conspiracy beliefs. Notably, people with the lowest level of education (lower secondary school) endorsed fewer COVID-19 conspiracy beliefs (B -0.089, vs. upper secondary school). Furthermore, higher socioeconomic backgrounds-such as higher income, higher wealth, and regular employment-were associated with endorsing conspiracy beliefs. Additionally, only 37.3% of respondents trusted the government of Japan, but paradoxically, trust in the government was positively associated with conspiracy beliefs (B 0.175, vs. distrust). ConclusionsConspiracy beliefs about COVID-19 were prevalent in about a quarter of the Japanese population. Certain groups are more likely to endorse conspiracy beliefs, and targeting interventions towards these groups might be efficient in stemming the spread of conspiracy beliefs.

ImportanceDiscrimination in healthcare disrupts trust and can negatively influence patients. However, the impact of experiencing discrimination on long-term patterns of healthcare utilization is unknown. ObjectiveTo assess how perceived discrimination in healthcare settings is associated with longitudinal patterns of doctor visits among middle-aged and older adults in the United States. DesignProspective cohort study of US adults in the Health and Retirement Study (HRS) who were followed every 2 years for up to 14 years (2008-2020). SettingUS population-based cohort study. ParticipantsAdults aged 50-80 years at baseline who completed the HRS psychosocial questionnaire, answered the question on discrimination in healthcare settings, had complete covariate information, and had at least two waves of follow-up data. ExposureDiscrimination in healthcare settings was measured at baseline as the self-reported frequency of "receiving poorer treatment than others from doctors or hospitals." Responses were dichotomized to indicate any experience of discrimination. Main Outcomes and MeasuresNumber of doctor visits in the prior two years were reported by participants at each wave. Group-based trajectory models (GBTM) were used to identify distinct longitudinal trajectories (patterns) of doctor visits over time. Multinomial logistic regression models were used to examine associations between discrimination in healthcare and trajectories of doctor visits while adjusting for sociodemographic, behavioral, and health-related factors. ResultsAmong 13,422 participants (mean age [~]63.0 years [{+/-}8.0]), approximately 19.4%, reported experiencing discrimination in healthcare at baseline. Results identified five major patterns of doctor visits over time: "Low" ([~]2 visits/year, 35.5%), "Frequent" ([~]4.5 visits/year, 33.3%), "Frequent-to-High" ([~]4.5 to 9 visits/year, 13.7%), "High-to-Frequent" ([~]13.5 to 6 visits/year, 10.3%), and "High" ([~]11+ visits/year, 6.3%). Discrimination in healthcare was more prevalent among participants with higher-utilization patterns and among those with greater disease burden and social vulnerability. Compared to participants with Low doctor visits, perceived discrimination was significantly greater in those with High-to-Frequent (relative risk ratio [RRR]=1.38; 95% CI, 1.17-1.63; P<.001) and High (RRR=1.62; 95% CI, 1.30-2.03; P<.001) patterns of doctor visits. Conclusions and RelevanceDiscrimination in healthcare settings is associated with greater numbers of doctor visits, possibly indicating it as a marker of poor quality of care. Key PointsO_ST_ABSQuestionC_ST_ABSIs perceived discrimination in healthcare settings associated with long-term patterns of doctor visits among middle-aged and older adults? FindingsIn this prospective cohort study of United States adults aged 50 to 80, perceived discrimination in healthcare was associated with increased likelihood of belonging to high-frequency doctor visit patterns over 14 years of follow-up, even after adjusting for sociodemographic and health-related factors. MeaningDiscrimination in healthcare may contribute to fragmented or intensive healthcare utilization patterns, underscoring the need to address discrimination as part of efforts to improve care quality and equity.

Ethnic minority populations faced a disproportionate impact of the COVID-19 pandemic. Loneliness, a significant public health issue, was exacerbated during the pandemic. Most previous studies used aggregated ethnic groups and overlooked underrepresented groups. This study explored ethnic inequalities in loneliness across 21 disaggregated ethnic groups in Britain during the COVID-19 pandemic. It used cross-sectional data (February to November 2021) from the Evidence for Equality National Survey (EVENS), with 14215 participants aged 18-75 from 21 ethnic groups in Britain. Weighted logistic regression models examined ethnic inequalities in loneliness across 21 disaggregated and 6 aggregated groups, both unadjusted and adjusted for socio-demographics. This study found higher odds of loneliness among most ethnic minority groups, with nuanced differences that were overlooked in aggregated analyses. Socio-demographics explained disparities for some ethnic groups, while differences in others remained after adjustment, suggesting additional factors driving these differences.

College students report alarmingly low helmet usage while riding bikes and other open-wheeled forms of transportation (OWTs), increasing risk of brain injury and skull fracture. Despite prior interventions, this problem persists, necessitating an updated examination of the current barriers to helmet usage, and how to effectively mitigate them. This study aimed to determine the effect of class year on helmet usage in American college students, and explore emerging trends with electric bikes, skateboards, and scooters. We created and distributed an online survey to undergraduate students at Stanford University in California (N = 400) who regularly used electric or non-electric bikes, skateboards, or scooters. This survey collected information on helmet usage, attitudes on bike safety, and demographics, and the findings were used to design a pilot intervention. Students who regularly wore helmets were recruited as peer agents (N=3) and were trained to ask friends and classmates to pledge to wear a helmet. We observed bike, scooter, and skateboard rides (N = 4885), and followed up with students who pledged to analyze their behavior change. We confirmed prior trends that most college students never or rarely wear a helmet, and the most common reasons for not wearing a helmet were "Helmets mess up my hair" (44%), "I dont see others wearing helmets" (43%), and "Its unlikely I will fall/crash" (34%). We also found that helmet usage was similarly low (48% of participants reported never wearing a helmet) across class years, but class years reported different reasons for not wearing a helmet. Lastly, there was no difference in helmet usage between electric and non-electric OWT users for any of the frequency categories (p=0.43 for daily, p=0.44 for a few times a week, p=0.77 for a few times a month, p=0.23 for rarely, p=0.15 for never), revealing that previous trends in helmet behavior also apply to American college students with electric OWTs. The pilot intervention resulted in a non-significant yet positive trend, and students who pledged demonstrated a behavior change (as measured by follow-up surveys about helmet usage) that persisted 3 weeks after the conclusion of the intervention. In addition to finding that past trends about helmet behavior in college students are still present, we discovered new trends on electric OWTs and class years in American college students. We also found that our peer agent program shows promise in modifying the behavior of college students.

BackgroundBoth the COVID-19 pandemic and containment policies caused widespread psychological distress, yet their independent effects remain unclear. Disentangling these effects could inform future responses that balance physical and mental health. This study sought to estimate the effect of lifting versus maintaining containment policies on psychological distress, independent of pandemic severity. MethodsWe conducted a state-level longitudinal analysis using the Behavioral Risk Factor Surveillance System (BRFSS), a representative survey of US adults, restricted to the pandemic period preceding widespread vaccine availability (April 2020 to April 2021). The exposure was lifting versus maintaining containment policies (school closures, workplace closures, event cancellations, and full lockdown) from the Oxford COVID-19 Government Response Tracker. Exposure was measured during periods of low (<25/100,000 new cases) or declining (>14 days) pandemic severity. The primary outcome was prevalence of psychological distress, derived from a BRFSS survey item corresponding to a PHQ-4 score [&ge;]6. FindingsThree causal inference approaches yielded consistent evidence of transient policy-lifting effects: (1) synthetic control analysis of Maine showed a temporary 5.5 percentage-point reduction in psychological distress lasting three months before returning to counterfactual levels; (2) within-state fixed effects found immediately after lifting full lockdown, distress decreased by 5.68 [-8.67, -2.69] percentage points, declining by 30 days (-3.24 [-6.88, 0.39]) and negligible at 60 days (-0.94 [-3.77, 1.89]); (3) target trial emulation detected no significant effects from lifting versus maintaining policies for 90 days. InterpretationLifting containment policies in the first year of the pandemic produced immediate but transient reductions in psychological distress. These results suggest that extended containment policies were unlikely to account for persistent increases in distress during this period.

ObjectiveWe aim to study the relationship between occupation distribution within each county and COVID-19 cumulative incidence and vaccination rate in the United States. MethodsWe collected county-level data from January 22, 2020 up to December 25, 2021. We fit multivariate linear models to find the relationship of the percentage of people employed by 23 main occupations. ResultsCounties with more health-related jobs, office support roles, community service, sales, production and material moving occupations had higher COVID-19 cumulative incidence. During the uptick of the "Delta" COVID variant (stratified period July 1-Dec 25), counties with more transportation occupations had significantly more COVID-19 cumulative incidence than before. SignificanceUnderstanding the association between occupations and COVID-19 cumulative incidence on an ecological level can provide information for precision public health strategies for prevention and protecting vulnerable workers. Impact StatementWe used data from US Census and COVID-19 data to explore the association between occupations and COVID-19 cumulative incidence and vaccination rate on an ecological level, which can provide information for precision public health strategies for prevention of spread of disease and protecting vulnerable workers.

IntroductionThis study investigated parents perspectives on access to oral health care and the Interim Canada Dental Benefit (CDB). In the context of Canadas national health insurance, which historically excluded dental care, the introduction of the Interim CDB in October 2022 represented a paradigm shift towards enhancing dental care accessibility for children under 12 years of age from lower-income families. MethodsThis study analyzed aggregate and de-identified data from the comprehensive online survey conducted by The Strategic Counsel for Health Canada, involving 2,203 parents from across Canada. The survey was administered in March of 2023. Paired/overlap t-test for means and paired/overlap z-test for percentages were performed, with statistical significance at p [&le;] 0.05. ResultsThe majority of participants expressed concerns regarding the costs (90.9%) and accessibility (80.9%) of dental care, indicated that regular dental visits for children is important (97.2%), and would take their children more frequently to dental appointments if had extra money (79.9%). Some of the barriers preventing regular dental visits for children included costs of service and transportation and lack of insurance. The majority of parents showed support for the Interim CDB (87%), with the greatest support coming from the provinces of Manitoba and Saskatchewan (90.4%). ConclusionThis research underscores the imperative for ongoing evaluation and policy refinement to ensure the CDCP effectively addresses the nuanced needs of Canadian families, fostering a more inclusive and accessible dental care system. Parents concerns regarding dental care and their support for the Interim CDB signal a clear mandate for improving program outreach and accessibility through the Canadian Dental Care Plan (CDCP). Knowledge Transfer StatementFindings from this study highlight the significant concern among parents regarding dental care affordability in Canada, reinforcing the necessity of programs like the Interim Canada Dental Benefit (CDB) and Canadian Dental Care Plan. High rates of support suggest a positive public reception of the CDB, which is crucial for policy interventions success. Concern about accessing dental services, despite the availability of the insurance, indicates ongoing barriers to dental care, suggesting areas for future policy refinements.

BackgroundDuring the first year of the COVID-19 pandemic, the most effective way to reduce transmission and to protect oneself was to reduce contact with others. However, it is unclear how behavior changed, despite numerous surveys about peoples attitudes and actions during the pandemic and public health efforts to influence behavior. MethodsWe used two sources of data to quantify changes in behavior at the county level during the first year of the pandemic in the United States: aggregated mobile device (smartphone) location data to approximate the fraction of people staying at home each day and digital invitation data to capture the number and size of social gatherings. ResultsBetween mid-March to early April 2020, the number of events fell and the fraction of devices staying at home peaked, independently of when states issued emergency orders or stay-at-home recommendations. Activity began to recover in May or June, with later rebounds in counties that suffered an early spring wave of reported COVID-19 cases. Counties with high incidence in the summer had more events, higher mobility, and less stringent state-level COVID-related restrictions the month before than counties with low incidence. Counties with high incidence in early fall stayed at home less and had less stringent state-level COVID-related restrictions in October, when cases began to rise in some parts of the US. During the early months of the pandemic, the number of events was inversely correlated with the fraction of devices staying at home, but after the fall of 2020 mobility appeared to stay constant as the number of events fell. Greater changes in behavior were observed in counties where a larger fraction voted for Biden in the 2020 US Presidential election. The number of people invited per event dropped gradually throughout the first year of the pandemic. ConclusionsThe mobility and events datasets uncovered different kinds of behavioral responses to the pandemic. Our results indicate that people did in fact change their behavior in ways that likely reduced COVID exposure and transmission, though the degree of change appeared to be affected by political views. Though the mobility data captured the initial massive behavior changes in the first months of the pandemic, the digital invitation data, presented here for the first time, continued to show large changes in behavior later in the first year of the pandemic.

Promoting resilience can reduce the mental health risks of cyberbullying victimisation in adolescents. We conducted a longitudinal cohort study with 9,969 adolescents (Millennium Cohort Study (MCS)) at ages 14-15 (baseline) and 17 (follow-up). We replicated our analyses in 4,240 adolescents (Longitudinal Study of Australian Children). The outcome was psychological distress at follow-up. Cyberbullying victimisation was a single-item question. Aim one identified modifiable resilience factors (exposures) associated with psychological distress. Aim two examined whether these resilience factors (moderators) interacted with the cyberbullying-distress association. 478/1,466 baseline variables were associated with distress after confounder adjustment (aim one). 31/478 potential resilience factors moderated the cyberbullying-distress association. 15 models replicated in the individual (n=8, e.g., happiness with friends), family and friends (n=3, e.g., sexual activities), structural (n=2, e.g., income sources), and learning environment (n=2, e.g., misbehaviour) domains. We identified several factors for further research on developing interventions to reduce adolescent cyberbullying mental health risks.

BackgroundInjury is one of the leading causes of hospitalization among Canadians and represents a substantial public health burden. However, at the population level, the lifetime risk of injury-related hospitalization is unknown. Estimating the lifetime risk of hospitalization due to injury among Canadians provides an intuitive and policy-relevant metric to inform the development of injury prevention strategies and health system planning. MethodsThis study used the Cumulative Risk Method to estimate the lifetime risk of at least one injury-related hospitalization among Canadians. Age-specific risks were calculated and summed under assumptions of a stable population and constant injury incidence. Estimates were adjusted for an average of 1.4 hospitalizations per person, and sensitivity analyses assessed the impact of varying this assumption. ResultsThe estimated lifetime risk of experiencing at least one injury-related hospitalization among Canadians was 42.0% (95% CI: 41.9% - 42.1%), corresponding to approximately one in every 2.4 individuals over the life course. Lifetime risk was slightly higher among females (42.1%, 95% CI: 42.0% - 42.3%) than males (41.3%, 95% CI: 41.1% - 41.4%), although males exhibited higher cumulative risk before age 65. Sensitivity analyses indicated that, under different assumptions regarding repeat hospitalizations, lifetime risk estimates ranged from 31.1% to 53.5%. DiscussionA substantial proportion of Canadians will experience at least one injury-related hospitalization over their lifetime. Estimates of lifetime risk provide a clear and easily interpretable metric that can communicate the burden of injury to the general population while highlighting to healthcare providers the importance of implementing sustained, population-level injury prevention strategies. What is already known on this topicInjury is a leading cause of hospitalization and death among Canadians, especially those under 45, and imposes a substantial healthcare and economic burden. What this study addsThis study estimates that one in every 2.4 Canadians will experience one or more injury-related hospitalizations over their lifetime. It also provides sex-specific differences and examines the impact of repeated hospitalizations on risk. How might this study affect research, practice, or policyThese findings provide a clear and easily understood measure of injury burden, which can guide public health planning, inform prevention strategies, and raise public awareness of the lifetime risk of serious injury.

ObjectivesIn mid-adolescence, to 1) examine cyclical associations between social media use and mental ill health by investigating longitudinal and bidirectional associations, dose response relationships, and changes in social media use and in mental health; 2) assess potential interaction effects between social media use and mental health with pre-existing early life vulnerabilities. MethodsLongitudinal data on 12,114 participants from the Millennium Cohort Study on social media use, depressive symptoms, self-harm and early life risk factors were used. ResultsWe found little support for the existence of cyclical relationships between social media use and mental health. Where detected, effect sizes were small. Dose response associations were seen in the direction of mental health to social media (depressive symptoms 1 time OR=1.22, 2 times OR=1.71; self-harm 1 time OR=1.17, 2 times OR=1.53), but not for social media to mental health. Changes in social media use and changes in mental health were not associated with each other. We found no evidence to suggest that either social media use or mental health interacted with pre-existing risk for mental ill health. ConclusionsFindings highlight the possibility that observed longitudinal associations between social media use and mental health might reflect other risk processes or vulnerabilities and/or the precision of measures used. More detailed and frequently collected prospective data about online experiences, including those from social media platforms themselves will help to provide a clearer picture of the relationship between social media use and mental health.

BackgroundWearing high-heeled shoes is associated with injury risk. During the COVID-19 pandemic, changes in work and social behavior may have reduced womens use of such footwear. MethodsThis study assessed the trend in high-heel related injuries among U.S. women, using 2016-2020 data from the U.S. Consumer Product Safety Commissions National Electronic Injury Surveillance System (NEISS). ResultsIn 2020 there were an estimated 6,290 high-heel related emergency department visits involving women ages 15-69, down from 16,000 per year in 2016-2019. The 2020 decline began after the start of the COVID-19 shutdowns on March 15. There was no significant change in the percentage of fractures or hospital admissions. ConclusionsThe COVID-19 pandemic was associated with a decline in reported injuries related to high-heeled shoes among US women. If this resulted from fewer women wearing such shoes, and such habits influence future behavior, the result may be fewer injuries in the future.

IntroductionElectronic nicotine delivery systems (ENDS) products continue to evolve, and so ongoing analysis of transition rates over time is important for tracking real-world associations between ENDS and cigarette use and for providing the information necessary to project future public health outcomes. MethodsUsing the Population Assessment of Tobacco and Health (PATH) Study Waves 6-7 (2021-2022), we applied a Markov multistate transition model to estimate transition rates for initiation and cessation of each product. We estimated one-year transition probabilities for each transition. These results were compared to estimated rates and probabilities in Waves 1-6 (2014- 2021). ResultsThe fraction adopting ENDS use in 2021-22 among those who had never previously established tobacco product use, those not currently using tobacco products, and those currently smoking cigarettes increased to 0.5% (95% confidence intervals [CI]: 0.4, 0.6%), 2.7% (95% CI: 2.3, 3.2%), and 6.8% (95% CI: 6.1, 7.6%), respectively. These increases were driven by young adults (ages 18-24), with respective transition fractions of 2.7% (95% CI: 2.3, 3.2%), 23.6% (95% CI: 20.2, 27.0%), and 19.2% (95% CI: 14.0, 24.5%). The fraction of adults who transitioned from dual cigarette and ENDS use to cigarette-only use remained around 25% (26.2% [95% CI: 21.7, 30.7%]), while the fraction who transitioned to ENDS-only use increased to 24.2% (95%CI: 20.5, 27.9%). The increase in the dual to ENDS-only use transition was also driven by young adults (34.4% [95% CI: 26.2, 42.6%]) and adults ages 25-34 (29.4% [95% CI: 23.1, 35.7%]). ConclusionPublic health efforts are needed to promote cigarette cessation among older adults, specifically. What this paper addsO_ST_ABSWhat is already known on this topicC_ST_ABSO_LITransitions in cigarette and ENDS use have been changing over time. Young adults have been early adopters of ENDS, with older adults less likely to try ENDS or to completely switch from cigarettes to ENDS. C_LIO_LIFrequency of product use likely impacts the likelihood of product quitting or switching. C_LI What this study addsO_LIWe found increasing adoption of ENDS among adults who have never smoked, those not currently using cigarettes or ENDS, and those using cigarettes only. These patterns were driven by young adults, with little cigarette cessation or switching to ENDS among older adults. C_LIO_LIDaily (vs non-daily) use of ENDS facilitated cigarette cessation among those using cigarettes and ENDS, but it was a barrier to ENDS cessation among those using ENDS only. C_LI How this study might affect research, practice, or policyO_LIPublic health efforts are needed to promote cigarette cessation among older adults who smoke, many of whom may already be experiencing the health effects of tobacco use. C_LIO_LIStudies are needed to develop strategies for leveraging ENDS to maximize smoking cessation while also helping those who successfully quit smoking to avoid long-term ENDS use. C_LI

Public health agencies have recommended that the public wear face coverings, including face masks, to mitigate COVID-19 transmission. However, the extent to which the public has adopted this recommendation is unknown. An observational study of 3,271 members of the public in May and June 2020 examined face covering use at grocery stores across Wisconsin. We found that only 41.2% used face coverings. Individuals who appeared to be female or older adults had higher odds of using face coverings. Additionally, location-specific variables such as expensiveness of store, county-level population and county-level COVID-19 case prevalence were associated with increased odds of using face coverings. To our knowledge, this is the first direct observational study examining face covering behavior by the public in the U.S., and our findings have implications for public health agencies during the COVID-19 pandemic.

While evidence for the importance of transmission of SARS-CoV-2 from contaminated surfaces is limited, ozone disinfection methods have been considered for surface cleaning as a response to stopping the spread of the virus in educational settings. This rapid evidence summary aimed to search the available literature and summarise findings on the surface survival of SARS-CoV-2, efficacy and effectiveness of ozone machines against SARS-CoV-2, and benefits and harms caused by using these cleaning technologies, including their impact on health. Alternative cleaning technologies, such as light-based technologies and hydrogen peroxide vapour, were also investigated. Findings indicate that gaseous ozone can inactivate different bacteria and viruses, although there is a lack of direct evidence investigating the effect of these cleaning methods on SARS-CoV-2 in real-world settings, specifically in schools. However, regarding harm, ozone is a highly reactive oxidising agent, and high concentrations can contribute to decay of building materials, and health issues (mainly respiratory) by direct exposure or by-product formation. Therefore, leading environmental health organisations do not recommend the use of ozone cleaning technologies in real-world settings, such as schools. Research and policy focus may need to shift towards other interventions that could help reduce transmission, and consequently minimise disruption to education. Funding statementThe Wales Centre for Evidence Based Care was funded for this work by the Wales Covid-19 Evidence Centre, itself funded by Health & Care Research Wales on behalf of Welsh Government. TOPLINE SUMMARYO_ST_ABSWhat is a Rapid Evidence Summary?C_ST_ABSThis Rapid Evidence Summary was completed in two weeks to inform policy- decision making. It is based on a systematic search of the literature, conducted in September 2021. Priority is given to studies representing robust evidence synthesis. No quality appraisal or evidence synthesis are conducted, and the summary should be interpreted with caution. Background / Aim of Rapid Evidence SummarySeveral non-touch disinfectant methods including ozone, light-based technologies, and hydrogen peroxide are being considered to reduce the risk of SARS-CoV-2 virus transmission to children and young people in educational settings. Concerns have been raised about the evidence of efficacy, effectiveness and safety of these technologies in these settings. We aimed to address the following research questions: O_LIWhat is the evidence for the surface survival of SARS-CoV-2? C_LIO_LIWhat is the evidence for the efficacy (in vitro) and real-life effectiveness (in situ) of ozone machines, light-based technologies and hydrogen peroxide vapour as air or surface disinfectants against SARS-CoV-2? C_LIO_LIWhat are the potential health effects of ozone, in particular for children and young people and the benefits and harms of using ozone machines? C_LI Key FindingsO_ST_ABSExtent of the evidence baseC_ST_ABSA total of 82 tertiary, secondary and primary evidence sources was included Recency of the evidence baseMost studies were published 2020-21, indirect evidence was included from earlier work from 2006 onwards Summary of findingsO_LISARS-CoV-2 fragments can be found on surfaces up to seven days later in the community but there is a lack of evidence whether these are viable C_LIO_LIWhen accounting for both surface survival data and real-world transmission factors, the risk of surface transmission after a person with COVID-19 has been in an indoor space is minor after 72 hours, regardless of last clean C_LIO_LIThere is evidence from experimental settings that ozone machines, light-based technologies and hydrogen peroxide do inactivate coronaviruses, including SARS-CoV-2 C_LIO_LIThere is a lack of evidence for the effectiveness of ozone machines, light- based technologies and hydrogen peroxide in real-world settings C_LIO_LIThere are uncertainties about training requirements for staff, methods for assurance of ozone removal and monitoring of occupational exposure C_LIO_LIThere is strong evidence of a causal relationship between short term ozone exposure and respiratory health issues; these can occur at very low concentrations of ozone; children with asthma are more at risk C_LIO_LIRooms using ozone machines need to be sealed off to avoid leakage of the ozone gas which is toxic at high concentrations C_LIO_LIOzone may react with materials in the room to form secondary pollutants (e.g. formaldehyde) C_LI The best quality evidenceO_LIThe US EPA 2021 does not recommend ozone for air cleaning and the UK SAGE EMG 2020a does not recommend technologies that "may generate undesirable secondary chemical products that could lead to health effects such as respiratory or skin irritation (medium confidence). These devices are therefore not recommended unless their safety and efficacy can be unequivocally and scientifically demonstrated by relevant test data" (SAGE EMG 2020a). C_LI Policy implicationsO_LIThere is no direct evidence for the effectiveness and safety of using ozone machines to deactivate SARS-CoV-2 in real-world educational settings for children, young people and staff C_LIO_LIThere is evidence for the risk of potential harm to children and young people of ozone machines from either ozone or secondary pollutants, in particular but not only, if used in uncontrolled ways in educational settings C_LI Strength of Evidence to dateO_LImoderate evidence for the surface survival of SARS-CoV-2 C_LIO_LIstrong evidence of causal relationship between short term ozone exposure and respiratory health issues C_LI

IntroductionDriving is an important mobility resource of increased outings and social activities among older adults; yet, little is known about the impact of driving restrictions on visiting places. We examined the association between driving status and the number of visiting places and the moderating role of alternative transportation use. MethodsThis cross-sectional study recruited community-dwelling individuals aged 65 years and above with functional independence from a suburban area through a mailed self-administered questionnaire. Visiting places were scored by assessing a total of 34 specific places over the past year using the Participation in ACTivities and Places OUTside Home Questionnaire (ACT-OUT); four subdomains of these paces were also measured: (A) consumer, administration, and self-care places (e.g., grocery shop, hairdresser, bank, post office, and government office); (B) places for medical and health care (e.g., the dentist or doctors office and hospital); (C) social, cultural, and spiritual places (e.g., family, relative and friends home, restaurant, cafe, and entertainment and cultural places); and (D) places of recreation and physical activities (e.g., park, sports facility, and forest, mountain, and sea). Driving status (self-driving or not) and other available transportation options (public transportation and ride-sharing with family/friends) were assessed. ResultsData from 432 individuals were analyzed (mean age 74.8 years; 52.8% women). Multivariable linear regression analysis revealed that not driving was associated with lower scores of visiting places ({beta}=-0.40, P<0.001). For subdomains, not driving was associated with lower scores for consumer, administration, and self-care places ({beta}=-0.32, P=0.007) and social, cultural, and spiritual places ({beta}=-0.44, P<0.001). Sensitivity analysis with inverse probability weighting confirmed the robustness of these results. Public transportation availability (trains and buses) moderated the association between not driving and visiting places. ConclusionsThese findings suggest that driving restrictions have the potential to reduce the visiting places among older adults, particularly life-related and social and cultural places.

Despite public health efforts, use of legal substances such as cigarettes, cannabis and e-cigarettes are common in Canada. Most policies focus on individual level factors, which do not account for possible influences of the environments to which people belong (i.e. neighborhoods). This study aimed to identify neighborhood-level risk factors for use of cigarettes, cannabis and e-cigarettes in the Canadian Partnership for Tomorrows Health cohort. Participants completed questionnaires on demographics and health behaviors including recent (30-d) use of cigarettes, cannabis and e-cigarettes. Geospatial neighborhood-level measures: deprivation, gentrification, household security, labor force participation, immigration and visible minority proportion were linked via postal codes. Regression models were built to understand associations between substance use and neighborhood factors. Neighborhood material deprivation, social deprivation, and household insecurity were positively associated with odds of using cigarettes, cannabis, and e-cigarettes. Odds of using these substances was higher for participants living in gentrified neighborhoods. Lower odds of cigarette, cannabis, and e-cigarette use were found for participants living in neighborhoods with a high proportion of recent immigrants and/or visible minorities. Evidence from this study suggests interventions aimed at reducing or preventing substance use should be multidimensional, encompassing strategies directed at both individuals and neighborhoods.

BackgroundStroke is the second leading cause of death globally. While daily toothbrushing is widely promoted for oral hygiene, the preventive impact of adjunctive practices such as dental flossing and interdental brushing on stroke remains unclear. ObjectivesThis study aimed to investigate the association between comprehensive oral hygiene behaviors and the risk of stroke. MethodsWe conducted a population-based retrospective cohort study using data from the National Health Insurance Service-Health Screening cohort in Korea. A total of 98,866 adults aged 40 years or older who underwent both general and oral health examinations during 2009-2010 were included. Participants were followed from January 2011 to December 2019. Individuals with pre-existing cardiovascular disease, death before baseline, or missing data were excluded. Oral hygiene practices, including daily toothbrushing frequency and weekly use of dental floss and interdental brushes, were self-reported. The primary outcome was stroke requiring hospitalization for [&ge;]2 days, classified as total, ischemic, or hemorrhagic stroke based on diagnostic codes. Multivariable Cox regression models were used to estimate adjusted hazard ratios. ResultsCompared to individuals with poor oral hygiene, participants who brushed their teeth at least twice daily and consistently used dental floss and interdental brushes showed a 23% lower risk of ischemic stroke. A significant trend was observed across oral hygiene behavior categories. ConclusionsFrequent toothbrushing, along with regular use of dental floss and interdental brushes, was associated with a reduced risk of ischemic stroke. Promoting comprehensive oral hygiene may offer additional benefits in stroke prevention. Key PointsO_ST_ABSQuestionC_ST_ABSIs improved oral hygiene practices, including toothbrushing, dental flossing, and interdental brushing, associated with a reduced risk of stroke? FindingsIn this nationwide retrospective cohort study that included 98,866 participants, more frequent toothbrushing, particularly dental flossing, and interdental brushing were significantly associated with up to a 23% reduction in the risk of ischemic stroke, compared to those in the poorest oral health care group. MeaningEnhancing oral hygiene practices such as toothbrushing, dental flossing and interdental brushing may significantly reduce the risk of stroke.

IntroductionWhile premium cigars have similar addictive, toxic, and carcinogenic constituents as other cigars and cigarettes, about 1% of the US adults reported premium cigar use from 2010 to 2019. This study aimed to understand public perceptions and discussions of premium cigars on Reddit, one of the most popular social media platforms. MethodsUsing keywords such as "premium cigar", we extracted 2,238 Reddit posts from Reddit Archive between July 2019 and June 2021. Among them, 1,626 posts were related to premium cigars. By employing the inductive approach, we manually coded each Reddit post on premium cigars to understand public perceptions and discussions of premium cigars by summarizing them into different topics and subtopics. ResultsLongitudinal analysis showed that the number of Reddit posts on premium cigars increased since June 2020. Content analysis showed that among Reddit posts related to premium cigars, the most popular topic is "Information sharing" (75.72%), in which Reddit users shared their perceptions about premium cigars, asked for advice, and provided some recommendations about premium cigars. Over one-quarter of posts (27.17%) are sharing user experiences of premium cigars (such as taste). Nearly one-fifth (18.99%) of posts are discussing the affordability of premium cigars. In addition, 7.87% of posts are discussing legal/policy issues related to premium cigars, and 6.82% of posts are related to the health risks of premium cigars compared to cigarettes. ConclusionsPublic perceptions including misperceptions, user experiences, and affordability related to premium cigars have been actively discussed on Reddit. ImplicationsWith the increasing trend of premium cigar use, it is necessary to understand how premium cigars are perceived by the public and why they are becoming more popular. This study provides the first evidence on public perceptions and discussions of premium cigars on social media, which could provide useful information on future regulatory policies that aim to prevent the prevalence of premium cigars to protect public health.